PE/Shock NCLEX questions

What lab studies would you expect to be ordered for a patient suspected of a PE? a.CBC b.Coagulation Study c.BMP d.Troponin e.BNP f.D-dimer

Answer & Rationale: C,D,E,F- page 589 - laboratory assessment

The patient presents to the ER following a car crash. Upon assessment the nurse notes paradoxical chest wall movements. Which intervention is the priority to improve oxygenation? a.Nerve block epidural b.Shallow breathing exercises c.Splinting with tape d.Suction every 2 hours

Answer: A Rationale: pg 607. Pain management is the priority so adequate ventilation is maintained.

Patient has history of DVT and is post op knee replacement. What are priority nursing interventions to prevent VTE/PE? Select all that apply. •A) SCD •B) Oxygen Therapy as ordered •C) Non-Slip Socks •D) Anticoagulation Administration •E) Call Light within Reach

Answer: A & D Rationale: Page 587...QSEN Box (Prevention of Pulmonary Embolism)

Which patient is at greatest risk of developing acute respiratory distress syndrome (ARDS)? A.24-year-old male admitted with blunt chest trauma and aspiration B.56-year-old male with a history of alcohol abuse and chronic pancreatitis C.72-year-old male post heart valve surgery receiving 1 unit of packed red blood cells 82-year-old female on antibiotics for pneumonia

ANS: A All patient scenarios create a risk for ARDS. However, the trauma patient with direct chest injury and known aspiration is at greatest risk. ARDS risk factors include direct lung injury (most commonly aspiration of gastric contents), systemic illnesses, and injuries. The most common risk factor for ARDS is sepsis. Other risk factors include bacteremia, trauma with or without pulmonary contusion, multiple fractures, burns, massive transfusion, near drowning, post-perfusion injury after cardiopulmonary bypass surgery, pancreatitis, and fat embolism.

A patient is being discharged to home on warfarin (Coumadin) therapy to manage an acute pulmonary embolism. Which patient response indicates a need for further teaching by the nurse? A."I should limit my alcohol consumption." B."I should eat more green leafy vegetables like spinach." C."I should take the medication at the same time every day." D."I should make a doctor's appointment for weekly blood draws."

ANS: B Patients who experience a venothromboembolism/pulmonary embolism are frequently discharged on anticoagulant therapy (e.g., warfarin [Coumadin]). The patient should be educated to understand the risks and monitoring of this drug to include weekly monitoring for therapeutic levels, consistency in dosing regimens, and foods to avoid (e.g., leafy green vegetables, green tea, alcohol, cranberry juice).

A patient in acute respiratory failure is classified as having ventilatory failure. The nurse understands that which finding is a potential cause of ventilatory failure? A.Pulmonary edema B.Hypovolemic shock C.Pulmonary embolus D.Opioid analgesic overdose

ANS: D Acute ventilatory failure is the type of problem in oxygen intake and carbon dioxide removal (ventilation) and blood delivery (perfusion) that causes a ventilation-perfusion (V/Q) mismatch in which perfusion is normal but ventilation is inadequate. It occurs when chest pressure does not change enough to permit air movement into and out of the lungs. As a result, too little oxygen reaches the alveoli and carbon dioxide is retained. Opioid analgesic overdose is a possible cause of ventilatory failure. The other choices listed are related to oxygenation failure.

A client asks what makes them more at risk for a VTE that could lead to a PE. The nurse states what risk factors can lead to the development of a PE? Select all that apply. a.Prolong immobility b.Central lines c.Anorexia d.Smoking e.Pregnancy f.Sepsis

Answer & Rationale: A, B, D, E- page 587- risk factors

The nurse is caring for a client with dyspnea, oxygen sat of 87% on room air, and new onset chest pain. What would the nurse priority action? a.Apply oxygen via Nasal Cannula b.Position patient in high fowlers position c.Trendelenburg position bed d.Assess resp status every 30 minutes e.Assess for petechia f.Assess resp status every 2 hours

Answer & Rationale: A,B,D, E - best practice for patient quality of care- page 589 T

What is the first sudden change in a patient's condition when respiratory distress syndrome is developing? • a)Refractory hypoxemia b)Sepsis c)Increased respiration rate d) Abnormal lung sounds

Answer: A Rationale: First cardinal sign of hypoxemia is refractory hypoxemia which is defined as inadequate arterial oxygenation despite optimal levels of inspired oxygen or supplemental oxygenation . Iggy page 595 (O2 levels do not improve even with O2 therapy applied)

A patient has presented to the ER with Flail chest. What interventions would the nurse take with this patient? (Select all that apply) A) humidified oxygen B) nerve block C) splint chest with tape D) Analgesics

Answer: A Rationale: Iggy p. 608, Assess for and relieve pain with prescribed analgesic drugs by IV, epidural, or nerve block route. Humidified oxygen, pain management, promotion of lung expansion, and positioning are interventions for flail chest. It is contraindicated to splint the chest with tape.

A nurse is teaching a new graduate nurse about intervention for a patient in Acute Respiratory Failure. Which statement by the new graduate nurse shows understanding of this concept? A) " I will sit the patient upright to promote relaxation and promote easier breathing." B) "I will help decrease the patient's anxiety by taking them on a walk." C) "I will encourage the patient to perform all self-cares." D) " I will teach the patient the importance of pursed lip breathing."

Answer: A Rationale: Iggy, p. 594, Help the patient find a position of comfort that allows easier breathing (usually a more upright position). To decrease anxiety occuring with dyspnea, help him or her to use relaxation, diversion, and guided imagery. Start energy conserving measures, such as minimal self-care and no unnecessary procedures.

A patient diagnosed with a PE is on day 5 of heparin therapy and switching to warfarin PO for home management. Patient's current PTT is 65 and INR is 2.5 which has not changed in the last 24 hours. What is an expected order from the doctor? a.Turn off heparin b.Bolus heparin per protocol c.Stay at current heparin rate d.Increase warfarin dose

Answer: A Rationale: Page 590 and 591 under National Patient Safety Goals - warfarin is usually started after 1-2 days on heparin therapy and the INR is in therapeutic range. Will turn off Heparin and continue PO Warfarin so the patient can go home.

A client with respiratory failure presents with the following vital signs; BP 128/88, SpO2 of 88%, pulse of 91, respirations of 20, and temp of 97.8. What does the nurse recognize as the priority intervention? a.Place the patient on oxygen as prescribed b.Encourage deep breathing c.Assess the clients pain level d.Administer a corticosteroid

Answer: A Rationale: pg 594 Iggy. Oxygen therapy is appropriate for any patient with acute hypoxemia. Oxygen would be a priority to keep the arterial oxygen level above 60 mm Hg while treating the cause of respiratory failure. Deep breathing is not a priority at this time. Pain level is important but not a priority at this time. Corticosteroid is not a priority

A patient is admitted for possible PE. What cardiac signs and symptoms would the nurse identify as a priority? Select all that apply. •A) Tachycardia •B) Distended Neck Veins •C) Syncope •D) Cyanosis •E) Hypotension

Answer: A, B, C, D, E Rationale: Page 588...Cardiac symptoms related to decreased tissue perfusion include tachycardia, distended neck veins, syncope (fainting or loss of consciousness) cyanosis, and hypotension.

The nurse walks in on a patient with severe hypoxemia saturation in the 70's, which calls for an emergency intubation. Which of the following professionals can perform this procedure? (Select all that apply) a.Anesthesiologist b.Nurse practitioner c.Nurse anesthetist d.Respiratory therapist e.ICU charge nurse

Answer: A, C, D Rationale (Page 598 in the Iggy Med Surg Book. Listed under the endotracheal tube paragraph. An anesthesiologist, nurse anesthetist, or respiratory therapist usually perform the intubation.

In addition to notifying the pulmonary health care provider, what is the most important action for the nurse to take first for a client with a pulmonary embolism (PE) whose arterial blood gas (ABG) values are pH 7.28, PaCO2 50 mm Hg, PaO2 62 mm Hg, and HCO3− 24 mEq/L (24 mmol/L)? a. Increasing the oxygen flow rate b. Administering sodium bicarbonate c. Assessing for the presence of adventitious lung sounds d. Having the client breathe rapidly and deeply into a paper bag

Answer: A- use this as a bonus question and students have to say why These ABG values indicate respiratory acidosis (low pH and high PaCO2) and severe hypoxemia (low PaO2) from greatly reduced gas exchange.This client needs more oxygen now.by a low partial pressure of arterial carbon dioxide (PaCO2 of 30 mm Hg) and a high pH (7.46). Breathing more rapidly and deeply into a paper bag would decrease oxygen levels and increase CO2 further, making hypoxemia and acidosis worse. The bicarbonate level is normal and requires no intervention. Adventitious sounds are expected and identifying them is not the first priority.

With which client will the nurse take immediate actions to reduce the risk for developing a pulmonary embolism (PE)? • A. A 25 year old receiving IV antibiotics through a peripheral line B. A 36 year old who had open reduction and internal fixation of the tibia C. A 50 year old with type 2 diabetes mellitus and cellulitis of the leg D. A 72 year old with dehydration and hypokalemia taking oral potassium supplements

Answer: B To reduce the risk for developing PE, the nurse provides immediate interventions for the client who had an open reduction and internal fixation of the tibia. Lower limb surgery and perioperative immobility are high risks for deep vein thrombosis (DVT) formation and PE. Peripheral infusion of antibiotics in a younger client is not a significant risk for PE. Although dehydration is a mild risk for thrombosis, this is not as common as thromboembolic complications after orthopedic surgery.

Drugs from which class will the nurse prepare to administer as first-line therapy for a client just diagnosed with pulmonary embolism (PE)? a. Antibiotics b. Anticoagulants c. Antidysrhythmic d. Antihypertensives

Answer: B A PE is collection of particulate matter (solids, liquids, or air) that enters venous circulation and lodges in the pulmonary vessels. Anticoagulants are the first-line therapy drugs for this problem, even if the actual particulate matter is not a clot. Anything lodged in the blood vessels will cause clot formation around it. Anticoagulants help prevent new clots from forming in the area and extension of existing clots.Depending on other problems cause by a PE, antibiotics, or antidysrhythmics may also be used but not always. Clients with PE are hypotensive, not hypertensive.

The nurse is rounding on a ventilated patient and the alarm is going off. What is the priority action the nurse must take first? a.Check the alarm settings b.Examine the patient c.Bloop pressure d.Reposition patient

Answer: B Rationale (Page 601 Iggy Med Surg Book. Listed under nursing management paragraph. When caring for a ventilated patient, be concerned with the patient first and the ventilator second. If the ventilator alarm sounds, examine the patient for breathing, color, and oxygen saturation before assessing the ventilator.

A parent of a pediatric patient experiencing acute respiratory failure asked the nurse what caused this to happen to their child. What is the most appropriate response from the nurse explaining this to the parent? A) " Increased blood flow to the lungs, which is caused by the decreased amount of surfactant in the lungs." B) " Decreased blood flow to the lungs, which is caused by the decreased amount of surfactant in the lungs." C) " Increased blood flow to the lungs, which is caused by the increased amount of surfactant in the lungs." D) " Decreased blood flow to the lungs, which is caused by the increased amount of surfactant in the lungs."

Answer: B Rationale: MCH p. 1150, In ARDS, the lungs become stiff as a result of surfactant inactivation; gas diffusion is impaired, and eventually bronchiolar mucosal swelling and congestive atelectasis occurs.

What is the nurse's priority in between intubation attempts? a.Suction after every attempt b.Provide oxygen by mask c.Reattempt intubation right away d.Prepare for a tracheostomy

Answer: B Rationale: Page 598 Prevents hypoxemia and cardiac arrest, only 15-30 seconds in between attempts, 30 being max.

A nurse enters her patient's room and observes the client with a BP of 88/52 with reports of dyspnea and chest pain. What is the nurse's priority action? a.Assess client b.Notify rapid response team c.Take a full set of vitals d.Use therapeutic communication to calm the patient

Answer: B Rationale: RRT is needed for speedy diagnosis and treatment- manifestations of a PE- 588 Critical Rescue Box

The nurse is caring for a patient on mechanical ventilation. What actions will the nurse perform? (Select all that apply) a.Take vital signs every 2 hours b.Assess the needs for suctioning every 2 hours c.Reposition the patient every 4 hours d.Perform mouth cares at least every 12 hours

Answer: B & D Rationale (Page 600 Iggy Med Surg Book. Listed under the best practice for patient safety & quality care red box. Care of the patient receiving mechanical ventilation. Vital signs every 4 hours. Assess the needs for suctioning every 2 hours. Reposition the patient every 2 hours. Perform mouth cares at least every 12 hours.

What is included in the ventilator bundle? Select all that apply. a.Keep head of bed elevated at least 20 degrees b.Perform oral cares per policy c.Ulcer prophylaxis d.Aspiration prevention e.Pulmonary hygiene f.Proper hand hygiene g.Suctioning q 2 hours

Answer: B, C, D, E, F Rationale: Page 605, Head of bed should be elevated to at least 30 degrees, suctioning should be PRN, all other answers are correct

The nurse is caring for a patient recently intubated. What is the priority nursing action when caring for an intubated patient? a.Oxygen therapy b.Sitting the patient up at a 30-degree angle c.Maintain a patent airway d.Check lactate lab value

Answer: C Rationale (Page 599 in the Iggy Med Surg Book. Listed under the Nursing care section. The priority nursing action when caring for an intubated patient is maintain a patent airway.

The nurse is assessing a patient who has been recently extubated. Which finding is the most concerning? a.Patient has a sore throat b.Patient has a non-productive cough c.Nurse hears stridor sounds d.Patient exhibits mild dyspnea

Answer: C Rationale (Page 606 Iggy Med Surg Book Critical rescue box. Monitor the patient frequently to recognize symptoms of obstruction. When stridor or other symptoms of obstruction occur after extubating, respond by immediately initiating the Rapid Response Team before the airway becomes completely obstructed.

A patient is showing signs of acute respiratory distress, the nurse would recognize the cardinal symptom as ____? A) Decreased pulmonary compliance B) dyspnea C) Refractory hypoxemia D) Ground glass opacities on x-ray

Answer: C Rationale: Iggy p. 595, Acute respiratory distress syndrome is acute respiratory failure with these features: refractory hypoxemia, decreased pulmonary compliance, dyspnea, non-cardiac associated bilateral pulmonary edema, and dense pulmonary infiltrates on x-ray. Refractory hypoxemia is the cardinal feature of ARDS.

A patient is receiving heparin therapy for history of pulmonary embolism. Upon assessment the nurse notices petechia across the chest and oozing at the IV site. What would be the nurse's priority action? •A) Increase the dose of heparin •B) Continue to monitor as this is an expected finding •C) Administer Protamine Sulfate •D) Call a rapid response

Answer: C Rationale: Page 591...Anticoagulation and fibrinolytic therapy can lead to excessive bleeding. The antidote for heparin is protamine sulfate.

When assessing for signs of decreased gas exchange in mechanical ventilation, the nurse recognizes which symptoms are not an indication of decreased gas exchange? a.Cyanosis b.Low O2 saturation c.Low ETCO2 d.Anxiety

Answer: C Rationale: Page 599, critical rescue: Assess and recognize. Indications of impaired gas exchange (cyanosis, low O2 sat, high ETCO2 and anxiety)

Which assessment findings in a postoperative client suggest to the nurse the possibility of a pulmonary embolism (PE) and pulmonary infarction? a. Fever and tracheal deviation b. Paradoxical chest movements c. Hemoptysis and shortness of breath d. Audible wheezing on inhalation and exhalation

Answer: C Symptoms of a PE with infarction include profound shortness of breath and bloody sputum (hemoptysis) from poor gas exchange and hypoxic damage to lung tissues. Paradoxical chest movements are associated with a flail chest, not PE. Tracheal deviation is associated with a pneumothorax. Audible wheezing on inhalation and exhalation is a partial obstruction of the tracheobronchial tree.

What is the basis for the decreased oxygen saturation the nurse assesses in a client with a pulmonary embolism (PE)? a. Partial bronchial airway obstruction b. Increased oxygen need resulting from a septic clot PE c. Thickened alveolar membranes and poor gas exchange d. Shunting of deoxygenated blood to the left side of the heart

Answer: D A PE lodges in the blood vessels decreasing perfusion to a lung area, which wastes ventilation. When this blood that has not been oxygenated is returned to the left side of the heart, it dilutes the oxygen concentration of the arterial blood entering systemic circulation.PE does not block bronchial airways or thicken alveolar membranes. A septic clot is not the same as general sepsis, which when widespread, does increase tissue metabolism and the need for more oxygen.

•Which lab indicates probable Pulmonary Embolism? • •A) CBC •B) PT/INR •C) PTT •D) D-Dimer

Answer: D Rationale: Page 589...The d-dimer rises with fibrinolysis. When the value is normal or low it can rule out a PE. However, even if the value is high other diagnostic testing is needed to determine whether a PE has occurred.

When symptoms of respiratory depression develop during mechanical ventilation, what action should the nurse take? a.Apply nasal cannula at 10 L/min b.Raise head of bed to 45 degrees c.Increase PEEP d.Remove ventilator and provide ventilation with a bag valve mask

Answer: D Rationale: Page 602- QSEN- critical rescue: This action allows quick determination of whether problem is with ventilator or the patient. If no ventilator problem is identified, reconnect the patient to the ventilator and request RT assistance

What is the nurse's best first action when assessing a client who was intubated a few minutes ago and finds the end-tidal carbon dioxide level is 0 and the SpO2 is 38%? a. Removing the endotracheal tube and ventilating the client with a bag-valve-mask b. Obtaining a different monitor and rechecking the end-tidal carbon dioxide level c. Documenting the finding in the electronic health record as the only action d. Initiating the Rapid Response Team

Answer: a A reading of 0 for the end-tidal carbon dioxide and the very low SpO2 level indicate that the endotracheal tube is not in the airway. Immediate action is needed. While it is present in the client's throat, its presence is preventing air from reaching the airways. Removing the tube and ventilating the client with a bag-valve-mask device is critical to saving the client's life. The nurse will perform these actions while having another health care worker call the Rapid Response Team.If the client's SpO2 was in the normal range, obtaining a different monitor and rechecking end-tidal carbon dioxide level would be a good action. However, the low oxygen saturation level indicates there is no time for rechecking the carbon dioxide level.

Which action will the nurse take first for a client being mechanically ventilated who begins to pick at the bedcovers? a. Assessing for adequate oxygenation b. Administering the prescribed sedating drug c. Explaining to the client that the tube helps with breathing d. Requesting that the family leave to decrease the client's agitation

Answer: a The best first action by the nurse would be to assess for adequate oxygenation. Restlessness, agitation, anxiety, and tachycardia are early symptoms of hypoxemia.Increasing sedation is not indicated for this client and may mask symptoms such as hypoxemia or worsening respiratory failure. Although the nurse may explain to the client that he or she is intubated, it does not take priority over assessing for hypoxemia. The presence of family members may decrease, not increase, the client's anxiety.

Which action will the nurse instruct a client with an endotracheal tube to perform during the time the tube is being removed? a. Inhale b. Exhale c. Cough d. Hold his or her breath

Answer: b The nurse instructs the client to inhale deeply right before extubation while the nurse deflates the tube cuff. The tube is removed while the client exhales. The nurse instructs the client to cough immediately after extubation.

Which action is a priority for the nurse to prevent harm for a client with a pulmonary embolism who is receiving a continuous heparin infusion? a. Assessing breath sounds b. Comparing pedal pulses bilaterally c. Monitoring the platelet count daily d. Assessing gums daily for indications of bleeding

Answer: c Daily platelet counts are a safety priority in assessing for heparin-induced thrombocytopenia (HIT), a potential side effect of heparin.Assessing breath sounds each shift is an important action, as is examining for indications of bleeding. However, identifying HIT early is a greater priority so that appropriate interventions can be initiated. Assessing bilateral pedal pulses is important if the source of the embolism is a venous thromboembolism (VTE) in the legs; however, this is not an important general action for a client with PE.

Which assessment finding on a client who is being mechanically ventilated with positive end-expiratory pressure indicates to the nurse a possible left-sided tension pneumothorax? a. The client has bloody sputum and wheezes. b. Left chest caves in on inspiration and "puffs out" on expiration. c. Chest is asymmetrical and trachea deviates toward the right side. d. The left lung field is dull to percussion and crackles are present on auscultation.

Answer: c Symptoms of tension pneumothorax include chest asymmetry, tracheal deviation toward the unaffected side, dyspnea, absent breath sounds, jugular venous distention, cyanosis, and hyperresonance to percussion over the affected area. If not promptly detected and treated, tension pneumothorax is quickly fatal.Flail chest has paradoxical chest movement with a "sucking inward" of the loose chest area during inspiration and "puffing out" of the same area during expiration. Open pneumothorax presents with decreased breath sounds, hyperresonance, and poor respiratory excursion on the affected side. Pulmonary contusion presents with hemoptysis, dullness to percussion, and crackles or wheezes.

What is the best first action when the nurse assesses that the respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures but the ventilator tubing is clear? a. Humidifying the oxygen source b. Suctioning the tracheostomy tube c. Increasing the percentage of oxygen d. Remove the inner cannula of the tracheostomy

Answer: c The best first action by the nurse is to suction the tracheostomy tube. This will likely result in clear lung sounds and lower peak pressure.Humidifying the oxygen source may help mobilize secretions but is not an immediate helpful action. Increasing oxygenation does nothing to clear the airway of whatever is making it noisy and is elevating peak pressures. Removing the inner cannula of a ventilated client is contraindicated.

What is the primary emphasis for the nurse who is providing care to a client with acute respiratory distress syndrome (ARDS) currently in the exudative management stage of the disorder? a. Assessing for abnormal lung sounds b. Performing meticulous mouth during mechanical ventilation c. Assessing the client at least hourly for tachypnea and dyspnea d. Monitoring urine output to identify multiple organ dysfunction syndrome early

Answer: c The exudative phase includes early changes of dyspnea and tachypnea resulting from the alveoli becoming fluid filled and from pulmonary shunting and atelectasis. Early interventions focus on frequent assessment of respiratory status, supporting the client, and providing oxygen.Abnormal lung sounds are not present at this stage because the edema is present in the interstitial tissues and not in the airways. At this stage, clients are neither intubated nor being mechanically ventilated. Multiple organ dysfunction syndrome is not a feature of this stage.

Which action will the nurse take first while caring for a client being mechanically ventilation when the high-pressure alarm sounds? a. Comparing the ventilator settings with the prescribed settings b. Turning off the alarm then assess the need for suctioning c. Auscultating the client's breath sounds d. Notifying the respiratory therapist

Answer: c The nurse will first listen to the client's breath sounds. Assessment always begins with the client. A typical reason for the high-pressure alarm to sound is obstruction of airflow through the ventilator circuit, usually indicating the need for suctioning. Other reasons for the high-pressure alarm to be triggered included biting the endotracheal tube or tension pneumothorax.The nurse is concerned with the assessment of the client first, not with the ventilator or ventilator settings and does not turn off the alarms before assessing the client. Although an excessively high tidal volume could contribute to the high-pressure alarm sounding, this is not the nurse's first concern. The professional nurse possesses the skill to assess ventilator alarms; waiting for the respiratory therapist delays intervention.

What type of acid-base problem will the nurse expect in a client who is being insufficiently mechanically ventilated for the past 4 hours and whose most recent arterial blood gas results include a pH of 7.29? A. Metabolic acidosis with an acid excess b. Metabolic acidosis with a base deficit c. Respiratory acidosis with an acid excess d. Respiratory acidosis with a base deficit

Answer: c When a person being mechanically ventilated is insufficiently ventilated respiratory acidosis occurs with retention of carbon dioxide. The retained carbon dioxide is converted to hydrogen ions resulting in an acid excess. Bases have neither been lost nor retained in an acute respiratory acidosis. Insufficient ventilation does not cause any form of metabolic acidosis.

Which client will the nurse consider to be at the greatest risk for developing acute respiratory distress syndrome (ARDS)? a. A 22 year old with a fractured clavicle b. A 39 year old with uncontrolled diabetes c. A 56 year old with chronic kidney disease d. A 74 year old who aspirates a tube feeding

Answer: d ARDS is a type of acute respiratory failure with hypoxemia that persists even when 100% oxygen is given, decreased pulmonary compliance, dyspnea, bilateral pulmonary edema, and dense pulmonary infiltrates on x-ray (ground-glass appearance). It often occurs after an acute lung injury such as could result from aspiration of acidic gastric contents. Clients who are receiving tube feedings are at particular risk for lung damage by aspiration.Fractured clavicle, diabetes, and chronic kidney disease is associated with an increased risk for lung injury or ARDS.

Which new assessment finding in a client being managed for a pulmonary embolism (PE) indicates to the nurse that the client's condition is worsening? a. Distended neck veins in the high-Fowler position b. Increasing temperature c. Abdominal cramping d. Hand tremors

Answer: d Distension of neck veins in the upright (high-Fowler) position occurs with right-sided heart failure, which is a complication of PE. None of the other changes in assessment findings are directly associated with worsening PE.

Which action has the highest priority for the nurse to take to prevent harm for a client being mechanically ventilated with 100% oxygen for the past 24 hours who now has new-onset crackles, decreased breath sounds, and a PaO2 level of 95 mm Hg? a. Assessing cognition b. Preparing to suction the client c. Placing the client in the prone position d. Collaborate with PCP to lower the FiO2 level

Answer: d Prompt identification and correction of the underlying disease process and potential oxygen toxicity may require delivery of a lower FiO2. The pulmonary health care provider needs to be notified when PaO2 levels are greater than 90 mm Hg. Preventing harm from oxygen toxicity and absorptive atelectasis (new onset of crackles and decreased breath sounds) are essential. Oxygen toxicity is related to the concentration of oxygen delivered, duration of oxygen therapy, and degree of lung tissue present. The need for 100% oxygen delivery indicates that the client continues to require intubation and mechanical ventilation.Suction is performed when rhonchi or noisy breath sounds on the anterior chest below the sternal notch (upper airway) are present. Crackles and diminished breath sounds reflect fluid or poor exchange in the lower airway, not the need for suctioning. Although prone-positioning has been used for clients with acute respiratory distress syndrome (ARDS), is not the priority action and this client has not been diagnosed with ARDS.

Which ventilator mode does the nurse expect will be set for a client with a tracheostomy who is beginning to take spontaneous breaths at his own rate and tidal volume between set ventilator breaths? a. Assist-control (AC) ventilation b. Bi-level positive airway pressure (BiPAP) c. Continuous positive airway pressure (CPAP) d. Synchronized intermittent ventilation (SIMV)

Answer: d Synchronized intermittent mandatory ventilation (SIMV) is a ventilation mode in which volume and ventilatory rate are preset. It allows spontaneous breathing at the patient's own rate and tidal volume between the ventilator breaths to coordinate breathing between the ventilator and the client.BiPAP and CPAP are not used for clients who have an endotracheal tube. With assist-control ventilation, the preset tidal volume continues even when the client's own respiratory rate increases, which could lead to over-ventilation.

The nurse is caring for a patient on mechanical ventilation. What type of lung problems from mechanical ventilation should the nurse be aware of? Select all that apply. a. Barotrauma b. Biotrauma c. Overproduction of surfactant d. Volutrauma e. Increased muscle strength

Answers: A, B, D Rationale: pg. 604 Lung problems from mechanical ventilation include barotrauma, biotrauma, Volutrauma, Atelectrauma, and VALI/VILI.

The doctor orders the ventilator bundle for a patient that is at risk for VAP. The nurse recognizes which interventions are included in this order set? Select all that apply. a.Elevate HOB 30 degrees b.Prone position c.Oral care every 12 hours with a suction toothbrush d.Ulcer prophylaxis e.Suction every 6 hours

Answers: A, C, D Rationale: pg. 605 To prevent VAP, implement ventilator bundle that includes HOB 30 degrees, perform oral care with suction toothbrush q12 hours, ulcer prophylaxis, preventing aspiration, and pulmonary hygiene.

Major risk factors of VTE leading to a PE include? Select all that apply. •A) Advancing Age •B) Caffeine consumption •C) Obesity •D) Seasonal Allergies •E) Prolonged Immobility •F) Pregnancy

Answers: A, C, E, F Page 587...Major risk factors for VTE leading to PE are: Prolonged immobility, central venous catheters, surgery, pregnancy, obesity, advancing age, general and genetic conditions that increase blood clotting, history of thromboembolism, smoking, estrogen therapy, heart failure, stroke, cancer and trauma.

The nurse assesses a client with acute respiratory failure. The nurse understands that which of the following are common causes of ventilatory failure? Select all that apply. a. Sleep apnea b. COPD c. Central nervous system dysfunction d. Shock e. Pulmonary edema

Answers: A,C,E Rationale: Iggy page 594 Box 29.2

Which clients will the nurse monitor most closely for respiratory failure? (Select all that apply.) a. A 30 year old with a C-5 spinal cord injury b. A 35 year old using client-controlled analgesia c. A 40 year old with acute pancreatitis d. A 50 year old experiencing cocaine intoxication e. A 55 year old with a brainstem tumor f. A 65 year old with COVID-19 pneumonia

Answers: a, b, c, e, f Pressure on the brainstem may depress respiratory function. Acute pancreatitis is a risk factor for acute respiratory distress syndrome; abdominal distention also ensues, which can limit respiratory excursion. Clients with cervical and high thoracic spinal cord injuries are at high risk for respiratory failure because spinal nerves that affect the diaphragm and inter-costal muscles are affected. Opioids used in client-controlled analgesia are respiratory depressants and can depress the breathing center in the brainstem causing respiratory failure. Pneumonia, whether bacterial or viral, can result in oxygenation respiratory failure, especially in an older client who often has respiratory muscle weakness.Cocaine is a stimulant, which would not cause respiratory failure unless a stroke ensued.

Which assessment findings in a client at high risk for pulmonary embolism (PE) indicates to the nurse the probably presence of a PE? (Select all that apply.) a. Dizziness and syncope b. Worsening dyspnea for 3 days c. Inspiratory chest pain d. Productive cough e. Pink, frothy sputum f. Tachycardia

Answers: a, c, f Symptoms consistent with PE include: dizziness, syncope, hypotension, and fainting. Sharp, pleuritic, inspiratory chest pain, hemoptysis, and tachycardia are also characteristic of PE.Typically SOB and dyspnea associated with PE develops abruptly rather than gradually over 2 weeks. Productive cough is associated with infection. PE typically causes a dry cough. Pink, frothy sputum is characteristic of pulmonary edema.

For which problems will the nurse specifically assess when the low-pressure alarm of a client's mechanical ventilator sounds? (Select all that apply.) a. Ventilator tubing is under the client. b. Cuff leak in the endotracheal or tracheostomy tube. c. Client is not breathing. d. Mucous plugs are in the endotracheal tube. e. Leak in the ventilator tubing circuit. f. Client is attempting to breathe against the ventilator.

Answers: b, c, e Common causes of alarms indicating low-pressure include: cuff leaks in the endotracheal or tracheostomy tube, client stops breathing when a ventilator is in the "support" mode, and when a leak is present in the ventilator tubing circuit.Presence of increased airway secretions or mucous plugs, client coughing or gaging, client fighting or "bucking" the ventilators, anything that decreases airway size (i.e., bronchospasms), presence of a pneumothorax, displacement of the endotracheal tube further into the tracheal bronchial tree, and external obstruction of the tubing result in high-pressure, not low-pressure